Mission Care Center

In the surveyor’s words

From the most serious findings on record at Mission Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF755Nov 4, 2021

  Based on interview and record review, the facility failed to safeguard controlled medications (medications that can cause physical and mental dependence), as indicated in the facility's Controlled Medications policy and procedure, for two of two sampled residents (Resident 1 and Resident 2), by failing to: 1. Ensure unauthorized staff (Registered Dietitian [RD]) did not have access to the controlled medications of Resident 1 and Resident 2. 2. Ensure Licensed Nurse 1 (LVN 1) safeguarded the keys to the Medication Cart number two where controlled medications for Resident 1 and Resident 2 were kept. As a result, on 10/21/2021 at approximately 11:10 am, LVN 1 left the Medication Cart Keys unsupervised. […]

• No harm, potential for more than minimal, widespreadF925Aug 29, 2022

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent the presence of cockroaches (Small insects that cause the spread of bacterial infection.) in the facility. The deficient practice placed the 53 residents at risk of vector-borne diseases (Illnesses that result from infections transmitted to humans by insects, such as cockroaches.). On August 18, 2022, at 1:30 p.m. and 3:35 p.m., respectively, the Registered Environmental Health Specialist (REHS, is a health inspector who inspects various facilities and properties to determine conformance with applicable State laws and County Ordinance Code sections.) and the surveyor observed live cockroaches in the facility's kitchen. […]

• No harm, potential for more than minimal, patternF880Jul 25, 2026

  Based on interview and record review the facility failed to implement timely and appropriately the facility's policy and procedures for infection control of scabies (a tiny skin bug infestation caused by microscopic mites that burrow under the skin, leading to severe itching and a pimple-like rash) outbreak control measures for three of three sampled residents (Resident 1, Resident 2, & Resident 3). The facility failed to: 1.Identify and maintain an ongoing surveillance (line listing) for all facility staff, specifically including nursing and non nursing personnel, who were in direct contact with Resident 1 (admitted on [DATE] with diagnosis of scabies) and Resident 2 (diagnosed on [DATE] with scabies), as recommended by the Acute Communicable Disease Control (ACDC) Program, Scabies… […]

• No harm, potential for more than minimal, patternF812Mar 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper food safety and sanitation practices to prevent foodborne illness (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps) to the residents in accordance with the facility's policy and procedure titled Labeling and Dating of Foods. by failing to: 1.Perform hand hygiene after certified nurse assistant (CNA) 1 was observed touching a clean meal tray without washing or sanitizing hands after touching a dirty, soiled meal tray. […]

• No harm, potential for more than minimal, patternF814Mar 19, 2026

  Based on observation, interviews, and record reviews, the facility failed to maintain trash in covered, properly contained, and sanitary receptacles. Three out of 3 large trash bins were observed overflowing with waste on the ground. This failure created the potential for vermin infestation and infection riskFindings: During an observation on 3/16/2026 at 2:21 pm, in the facility's trash bin area, three large trash bins were overflowing with multiple paper cups and paper towels were on the ground next to the trash bins. During an interview on 3/16/2026 at 2:30 pm, with the Dietary Supervisor (DS), the DS stated the trash bins need to be covered and secured at all times. DS stated that overflowing trash bins can develop pests and rodents in the facility. […]